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Glossary of Terms



This glossary has been created to provide a practical, easy-to-use guide to terminology presently used for personal health records in the health information field. 

Advance Beneficiary Notice (ABN)

A form that you must sign if you are receiving healthcare items or services that Medicare does not or may not cover. By signing an Advance Beneficiary Notice (ABN), you certify that you will be paying for the treatment yourself.

Advocacy

The action of advocating, pleading for, or supporting a cause or proposal. A health advocate works on a patient’s behalf, using his or her own health-care expertise to promote the best interests of patients in settings everywhere from the doctor’s office to the Senate floor.

AHIMA

American Health Information Management Association. The professional membership organization for managers of health record services and healthcare information systems as well as coding services, provides accreditation, certification, and educational services.

Authorization for the release of information form

A form to obtain copies of information on your health care including, but not limited to, treatment records such as progress notes, laboratory results, history and physical reports, operative reports, and discharge summary reports. You will need to complete the form and return it to the facility as directed. Most facilities do charge for copies. The fee can only include the cost of copying (including supplies and labor), as well as postage if you request the copy to be mailed. It can take up to 60 days to receive your medical records, so ask when you can expect to receive the information you requested.

Authorization Forms

Copies of consents for admission, treatment, surgery, and release of information.

Capitation

A fixed per capita payment made periodically to a medical service provider (as a physician) by a managed care group (as an HMO) in return for medical care provided to enrolled individuals.

Caregiver

1. Any clinical professional (physician, nurse, technologist, or therapist, for example) who provides care directly to patients.
2. A nonprofessional who provides supportive assistance in a residential setting to a relative, friend, or client who is seriously ill.

Centers for Disease Control and Prevention (CDC)

A group of federal agencies that oversee health promotion and disease control and prevention activities in the United States. The division of the Department of Health and Human Services that is responsible for developing healthcare policy in the United States and for administering the Medicare program and the federal portion of the Medicaid program.

Centers for Medicare & Medicaid Services (CMS)

A division within the US Department of Health and Human Services (HHS) that works with states to administer Medicare and Medicaid. CMS also develops government healthcare policy and increases the efficiency of US healthcare transactions through the Health Insurance Portability and Accountability Act (HIPAA).

Civilian Health and Medical Program – Veterans Administration (CHAMPVA)

The federal healthcare benefits program for dependents of veterans rated by the Veterans Administration as having a total and permanent disability, for survivors of veterans who died from VA-rated service-connected conditions or who were rated permanently and totally disabled at the time of death from a VA-rated service-connected condition, and for survivors of persons who died in the line of duty.

Co-morbidity

The presence of two or more illnesses in the same person at the same time. Usually, these conditions are independent of one another, but have a significant impact on the patient’s length of stay at a facility.

Complication

Any disease or disorder that occurs during the course of (or because of) another disease.

Confidentiality

A legal and ethical concept that establishes the healthcare provider’s responsibility for protecting health records and other personal and private information from unauthorized use or disclosure.

Confidentiality Breach

An unauthorized disclosure of confidential information in which a patient’s private information, entrusted to another party, is disclosed by the other party without the patient’s consent.

Consent Forms

Copies of consents for admission, treatment, surgery, and release of information.

Consultation

An opinion about your condition made by a physician other than your primary care physician. Sometimes a consultation is performed because your physician would like the advice and counsel of another physician.

Continuum of Care

The range of services, professionals, and institutions that can treat an individual for a given illness or life stage. For example, the continuum of care for a newborn baby extends from prenatal to pediatric care.

CPT-4

Current Procedural Terminology, 4th Edition. The American Medical Association’s set of five-digit codes that describe medical procedures, services, and diagnostic tests for billing purposes. CPT-4 codes appear on Explanation of Benefits forms, appointment reviews, or medical bills. Consumers may look up codes on the AMA’s website. Medicare uses HCPCS codes rather than CPT-4.

Decryption

The activity of making clear or converting from code into plain text; “a secret key or password is required for decryption.”

Dept of Health & Human Services (HHS)

The cabinet-level federal agency that oversees all of the health-and-human-services-related activities of the federal government and administers federal regulations.

Diagnosis

A word or phrase used by a physician to identify a disease from which an individual patient suffers or a condition for which the patient needs, seeks, or receives medical care.

Discharge Summary

A concise summary of a hospital stay, including the reason for admission, significant findings from tests, procedures performed, therapies provided, response to treatment, condition at discharge, and instructions for medications, activity, diet, and follow-up care.

Electronic Health Record (EHR)

The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR has the ability to generate a complete record of a clinical patient encounter – as well as supporting other care-related activities directly or indirectly via interface – including evidence-based decision support, quality management, and outcomes reporting.

Empowerment

The opportunity for individuals to control certain uses and disclosures of their health information.

Encryption

The process of encoding a message so that it can be read only by the sender and the intended recipient. Encryption systems often use two keys, a public key, available to anyone, and a private key that allows only the recipient to decode the message.

Explanation of Benefits (EOB)

A form from your insurer that lists services provided, the amount billed, and payments to be made based on your health plan. The EOB includes the deductible, co-pay, and co-insurance that you may owe.


Flash Drive

A small, portable flash memory card that plugs into a computer’s USB port and functions as a portable hard drive. USB flash drives are touted as being easy-to-use as they are small enough to be carried in a pocket and can plug into any computer with a USB drive. USB flash drives have less storage capacity than an external hard drive, but they are smaller and more durable because they do not contain any internal moving parts. USB flash drives also are called thumb drives, jump drives, pen drives, key drives, tokens, or simply USB drives.

HCPCS

Similar to CPT-4 codes, Healthcare Common Procedure Coding System codes are used by Medicare to describe medical procedures, services, and diagnostic tests for billing purposes. HCPCS codes appear on Explanation of Benefits forms, appointment reviews, or medical bills. Reviewing these codes can help ensure that you are only paying for the services received.

Health Information Management (HIM)

This is the study of the principles and practices of acquiring, analyzing, and protecting digital and traditional medical information vital to providing quality patient care. HIM is the link to clinicians, technology designers, and information technology; and is the value-adding bridge between patients’ health information and payors, government, and regulating agencies. HIM practitioners demonstrate leadership and management of health information in all formats (paper, scanned, or computerized forms), and are a critical component of the electronic health record (EHR) workforce. Visit Health Information Careers and AHIMA’s Official Careers Page on Facebook for more information.

Health Information Management (HIM) Professionals

Health information management professionals are the caretakers and guardians of patient health information. They represent the patient’s interests in matters of privacy and security, information release, issues and guidelines regarding record access, and general consumer education about personal health records.
Those with health information management and health information technology careers manage all aspects of the content of medical patient records and patient information systems. Job responsibilities can include anything from information gathering and maintenance, data analysis and interpretation to designing, implementing, and maintaining health information technology systems. Visit Health Information Careers and AHIMA’s Official Careers Page on Facebook for more information.

Health Insurance Portability and Accountability Act (HIPAA)

The HIPAA Privacy Rule for the first time creates national standards to protect individuals’ medical records and other personal health information.
  • It gives patients more control over their health information
  • It sets boundaries on the use and release of health records
  • It establishes appropriate safeguards that health care providers and others must achieve to protect the privacy of health information
  • It holds violators accountable, with civil and criminal penalties that can be imposed if they violate patients’ privacy rights
  • And it strikes a balance when public responsibility supports disclosure of some forms of data – for example, to protect public health
For patients – it means being able to make informed choices when seeking care and reimbursement for care based on how personal health information may be used.
  • It enables patients to find out how their information may be used, and about certain disclosures of their information that have been made
  • It generally limits release of information to the minimum reasonably needed for the purpose of the disclosure
  • It generally gives patients the right to examine and obtain a copy of their own health records and request corrections
  • It empowers individuals to control certain uses and disclosures of their health information
For more detailed information about health privacy, visit Medical Privacy: National Standards to Protect the Privacy of Personal Health Information.

Healthcare Representative

Also known as a personal representative, a healthcare representative is appointed by you to make legal decisions about your care when you are no longer able. Under HIPAA, healthcare representatives have the legal right to make decisions about personal health information associated with treatment. Parents, legal guardians, and those with power of attorney are automatically considered healthcare representatives. Other individuals may become legal healthcare representatives, but regulations vary by state.

History and Physical

A document that describes any major illnesses and surgeries you have had, any significant family history of disease, your health habits, and current medications. It also states what the physician found when he or she examined you.

HMO

Health Maintenance Organization. People enrolled in this type of group health plan must choose their primary physician from a list of participating doctors. For any non-emergency hospital or specialty care, enrollees must get a referral from their primary physician.

Identification Sheet

A form originated at the time of registration or admission. This form lists your name, address, telephone number, insurance, and policy number.

Imaging Reports

Describe the findings of x-rays, mammograms, ultrasounds, and scans. The actual films are maintained in the radiology or imaging departments or on a computer.

Immunization Record

A form documenting immunizations given for disease such as polio, measles, mumps, rubella, and the flu. Parents should maintain a copy of their children’s immunization records with other important papers.

Lab Reports

Describe the results of tests conducted on body fluids. Common examples include a throat culture, urinalysis, cholesterol level, and complete blood count (CBC). Surprisingly, your health record does not usually contain your blood type. Blood typing is not part of routine lab work.

Living Will

A legal document that sets out the medical care an individual, or the principal, wants or does not want in the event that he or she becomes incapable of communicating his or her wishes. A living will is used by people whose wishes will be met should they reach a point when they are no longer able to make the decisions for themselves. For example, if a person sustained life-threatening injuries, or was incapacitated as a result of some terminal illness, the decisions about his or her health care will be his/hers as long as there is a living will. Without one, the decision becomes the responsibility of spouses, family members or other third parties.

Medical Power of Attorney

A Medical Power of Attorney is a document, signed by a competent adult, i.e., “principal,” designating a person that the principal trusts to make health care decisions on the principal’s behalf should the principal be unable to make such decisions. The individual chosen to act on the principal’s behalf is referred to as an “agent.”
The agent should be knowledgeable about your wishes, values, and religious beliefs, and in whom you have trust and confidence. In the event your agent does not know of your wishes, that agent should be willing to make health care decisions based upon your best interests. The person must be 18 years of age or older or a person under 18 years of age who has had the disabilities of minority removed.
An agent may make health care decisions on your behalf only if your attending physician certifies in writing that you are incompetent. Treatment may not be given to or withheld from you if you object. This is true whether or not you are incompetent.

Medical Record

A chronological written account of a patient’s examination and treatment that includes the patient’s medical history and complaints, the physician’s physical findings, the results of diagnostic tests and procedures, and medications and therapeutic procedures.

Medication Record

A list of medicines prescribed or given to you. This form often lists any medication allergies you may have.

Microfilm

A film bearing a miniature photographic copy of printed or other graphic matter, usually of a document, newspaper or book pages, etc., made for a library, archive, or the like. Microfilm allows for very compact storage of books and documents.


Notice of Privacy Practice

A Notice of Privacy Practice tells you how your information is used or disclosed and explains who has access to your information. You receive the notice the first time you visit a new healthcare provider, pharmacy, or hospital. You are asked to read and sign an acknowledgement that you received the notice. The law does NOT say you HAVE to sign it, but if you do, it helps the provider to document that you got the information.

Health insurance plans must also provide you with a Notice of Privacy Practice, so if you have health insurance, you received the notice in the mail. Insurance plans don’t ask for your signature.

For more detailed information about health privacy, visit Medical Privacy: National Standards to Protect the Privacy of Personal Health Information.

Operative Report

A document that describes surgery performed and gives the names of surgeons and assistants.

Pathology Report

Describes tissue removed during an operation and the diagnosis based on examination of that tissue.

Patient Gateway

An electronic link between patient and healthcare providers. It typically offers a way to request routine appointments, prescriptions, and referral authorizations as well as obtain quality health and disease information from your doctor’s office.

Patient Portals

Online applications that allow patients to interact and communicate with their healthcare providers. Most portal services are available online 24 hours a day. Patient Portals systems can be integrated into existing websites, widgets added on to existing electronic medical records systems or stand-alone websites that sell their services to healthcare providers. Patient Portals allow patients to interact with their medical information and medical providers through the internet. The lines between patient portals, electronic medical records and personal health records continue to blur as technologies improve.

Personal Health Record (PHR)

A personal health record (PHR) is a collection of important information that you maintain about your health or the health of someone you’re caring for, such as a parent or a child, which you actively maintain and update.
Important information your PHR should include:
  • Personal identification, including name and birth date
  • People to contact in case of emergency
  • Names, addresses, and phone numbers of your physician, dentist, and specialists
  • Health insurance information
  • Living wills, advance directives, or medical power of attorney
  • Organ donor authorization
  • A list and dates of significant illnesses and surgical procedures
  • Current medications and dosages
  • Immunizations and their dates
  • Allergies or sensitivities to drugs or materials, such as latex
  • Important events, dates, and hereditary conditions in your family history
  • Results from a recent physical examination
  • Opinions of specialists
  • Important tests results; eye and dental records
  • Correspondence between you and your provider(s)
  • Current educational materials (or appropriate web links) relating to your health
  • Any information you want to include about your health – such as your exercise regimen, any herbal medications you take and any counseling you may receive

Pathology Report

Describes tissue removed during an operation and the diagnosis based on examination of that tissue.

Patient Gateway

An electronic link between patient and healthcare providers. It typically offers a way to request routine appointments, prescriptions, and referral authorizations as well as obtain quality health and disease information from your doctor’s office.

Personal Health Record (PHR)

A personal health record (PHR) is a collection of important information that you maintain about your health or the health of someone you’re caring for, such as a parent or a child, which you actively maintain and update.
Important information your PHR should include:
  • Personal identification, including name and birth date
  • People to contact in case of emergency
  • Names, addresses, and phone numbers of your physician, dentist, and specialists
  • Health insurance information
  • Living wills, advance directives, or medical power of attorney
  • Organ donor authorization
  • A list and dates of significant illnesses and surgical procedures
  • Current medications and dosages
  • Immunizations and their dates
  • Allergies or sensitivities to drugs or materials, such as latex
  • Important events, dates, and hereditary conditions in your family history
  • Results from a recent physical examination
  • Opinions of specialists
  • Important tests results; eye and dental records
  • Correspondence between you and your provider(s)
  • Current educational materials (or appropriate web links) relating to your health
  • Any information you want to include about your health – such as your exercise regimen, any herbal medications you take and any counseling you may receive

Physician's Orders

Your physician’s directions to other members of the healthcare team regarding your medications, tests, diets, and treatments.

Power of Attorney

A legal document giving one person (called an “agent” or “attorney-in-fact”) the power to act for another person (the principal).
When incapacity is anticipated, a person may grant power of attorney to another person. Power of attorney is the legally recognized authority to act and make decisions on behalf of another party. This authorizes the designee to act on behalf of the person who is now incapacitated. The person with power of attorney is often responsible for making decisions regarding the disclosure of health information to others.
There are different types of power of attorney. Some grant very broad powers to the holder; others are limited to specific issues, such as consenting to healthcare.
There are many good reasons to make a power of attorney as it ensures that someone looks after your health care and financial affairs if you were to become incapacitated. You should choose a trusted family member, a proven friend or a reputable and honest professional. For more information, visit myPHR.com’s Power of Attorney page.

Privacy Breach

A violation of a patient’s private medical records by a third party that is not authorized to access these records without consent of the patient.

Privacy Officer

HIPAA’s Privacy Rule requires the designation of a “privacy official” by each covered entity, to be responsible for the “development and implementation” of the policies and procedures necessary for compliance. Covered entities must also designate a “contact person or office” to be responsible for providing information, receiving complaints and handling the administration of patients’ ‘records rights such as:
  • access
  • amendment
  • disclosure accountings
  • supplemental protections
  • confidential communications
  • authorizations for additional uses
For more detailed information about health privacy, visit Medical Privacy: National Standards to Protect the Privacy of Personal Health Information.

Problem List

A list of significant illnesses and operations you have had.

Progress Notes

Notes made by the doctors, nurses, therapists, and social workers caring for you that reflect your response to treatment, their observations and plans for continued treatment.

Registered Health Information Administrator

RHIAs are skilled in the collection, interpretation, and analysis of patient data. Additionally, they receive the training necessary to assume managerial positions related to these functions. RHIAs interact with all levels of an organization—clinical, financial, and administrative—that employ patient data in decision making and every day operations.
RHIAs enjoy job placements in a broad range of settings that span the continuum of healthcare including office-based physician practices, nursing homes, home health agencies, mental health facilities, and public health agencies. The growth of managed care has created additional job opportunities in HMOs, PPOs, and insurance companies. Prospects are especially strong in these settings for RHIAs who possess advanced degrees in business or health administration.
Visit AHIMA for more information on RHIAs.

Registered Health Information Technician (RHIT)

RHITs are health information technicians who ensure the quality of medical records by verifying their completeness, accuracy, and proper entry into computer systems. They may also use computer applications to assemble and analyze patient data for the purpose of improving patient care or controlling costs. RHITs often specialize in coding diagnoses and procedures in patient records for reimbursement and research. RHITs may serve as cancer registrars, compiling and maintaining data on cancer patients. With experience, the RHIT credential holds solid potential for advancement to management positions, especially if it is combined with a bachelor’s degree.
Although most RHITs work in hospitals, you will also find them in a variety of other healthcare settings including office-based physician practices, nursing homes, home health agencies, mental health facilities, and public health agencies. In fact employment opportunities exist for RHITs in any organization that uses patient data or health information such as pharmaceutical companies, law and insurance firms, and health product vendors.
Visit AHIMA for more information on RHITs.

USB Flash Drive

A small, portable flash memory card that plugs into a computer’s USB port and functions as a portable hard drive. USB flash drives are touted as being easy-to-use as they are small enough to be carried in a pocket and can plug into any computer with a USB drive. USB flash drives have less storage capacity than an external hard drive, but they are smaller and more durable because they do not contain any internal moving parts.
USB flash drives also are called thumb drives, jump drives, pen drives, key drives, tokens, or simply USB drives.

Vaccine

A substance made from weakened or killed disease-causing microorganisms. Vaccines are given to stimulate the body’s production of antibodies, which fight infection and help improve resistance to a disease.

Web Portal

Commonly referred to as simply a portal, a Web site or service that offers a broad array of resources and services, such as e-mail, forums, search engines, and on-line shopping malls. The first Web portals were online services, such as AOL, that provided access to the Web, but by now most of the traditional search engines have transformed themselves into Web portals to attract and keep a larger audience.

X-ray Reports

Describe the findings of x-rays, mammograms, ultrasounds, and scans. The actual films are maintained in the radiology or imaging departments or on a computer.